Analysis Introduction Since 1992, the TSB has systematically identified a number of safety deficiencies and issued over 30safety recommendations with a view to mitigating risk in the Canadian fishing industry. The most commonly encountered safety deficiencies stem from shortcomings in training and knowledge, poorly maintained vessels and inadequate survival equipment. Poor maintenance can lead to down-flooding through unsecured hatch covers or deck and bulkhead openings, while lack of knowledge can result in vessel modifications which adversely affect stability, or give rise to unsafe loading and operational practices. The TSB Macro-Analysis Project MAP-M99-43, developed in support of the TSB investigation into the sinking of the BrierMist,5 provides a review of the general situation of Canadian fishing vessel safety. While it focuses on the particular safety issues raised in the course of that investigation, these are equally relevant to the many other occurrences that happen each year. The executive summary of the project states that TSB statistics continue to indicate a relatively high number of fishing vessel accidents and casualties in relation to other commercial vessels. Improper loading and progressive flooding continue to be the primary factors in the capsizing and foundering of fishing vessels (seeAppendixD). Since the publication of the MAP-M99-43 in November1998, the frequency of vessels capsizing and foundering on the West Coast of Canada has not significantly decreased and many of the common safety deficiencies mentioned in this introduction are applicable to the loss of the Kella-Lee (seeAppendixE). These deficiencies include: questionable stability due to alterations to the vessel; the consequences of free surface effects; the failure to understand the significance of storm warnings; improperly secured deck openings; and, the lack of training in the use of survival equipment. Sinking Sequence In preparation for the return voyage, the main cargo boom was lowered and secured along the centre line of the vessel, in a nearly horizontal position, some 4m above the main deck. A riding sail was rigged from it to the after side of the main mast. The riding sail, in conjunction with the deployed paravane booms, was intended to reduce the rolling of the vessel in rough sea conditions. However, a riding sail is most effective when the vessel is stopped and maintained head to wind, either by lying to drift-nets or a sea anchor or by balancing with other sails. To be efficient, roll reduction, boomed-out paravanes require that the vessel maintains a relatively high forward speed. Given the circumstances, neither of these methods to reduce the vessel's rolling or maintain her head to wind were effective. In this occurrence, the malfunction of the steering gear and the sporadic partial loss of propulsion meant that the vessel's directional control was lost. Neither the riding sail nor the paravanes were effective in maintaining the vessel's head to wind, and the vessel became vulnerable to the prevailing heavy seas and high winds. The force of the wind acting on the combined wind surface of the hull, superstructure, mainmast, rigging, riding sail and deployed paravane booms, heeled the vessel to starboard, reduced its righting ability and retarded the vessel's recovery to the upright condition. While in this vulnerable state, some of the water shipped and retained on the main deck entered the superstructure through the open dutch door. It then down-flooded into the engine-room through the non-watertight hatches in the main deck, inside the galley area. Seawater also down-flooded into the fish hold through the small unsecured access openings in the main hatch cover. Because the vessel was already heeled to starboard by the force of the wind, the seas shipped and retained on the main deck, in combination with the down-flooded water below the main deck, which had gravitated to the starboard side, increased its angle of heel, preventing the vessel's recovery toward the upright. In general, few fishermen appreciate the substantial fluctuation and reduction of initial transverse stability, caused when water, even a few inches deep, is shipped and retained on deck, or contained below deck in tanks, bilges or holds. The fluctuation in statical stability in conjunction with the dynamic heeling and rolling effects of rough seas, combined to overcome the Kella-Lee's initial righting ability, causing the extreme angle of heel from which it was unable to recover. Vessel Inspection TC inspectors are required to ask the owner to advise them of any alterations or modifications done to the vessel since the last inspection, and rely on the accuracy of such information regarding any work or changes carried out. The onus is on the owner to fully inform TC of any significant alterations/modifications that have been carried out between inspections in order that an informed review and assessment of the vessel's condition may be made. The SFVIR require small fishing vessels to be inspected once every four years. In the case of the Kella-Lee, TC carried out quadrennial inspections in1984, 1989,1993and1997. However, TC did not follow up to ensure that the owner completed all outstanding items resulting from these quadrennial inspections. A follow-up inspection, confirming satisfactory completion of such work, would have resulted in the issuance of a S.I.C.29. The absence of S.I.C.29s from previous quadrennial inspections was not questioned by successive TC inspectors at subsequent inspections, and this practice continued up to the time of the occurrence. Such inspections would have encompassed the Kella-Lee's hatch covers and weather-tight openings, the life-saving equipment and the status of the battery-powered distress equipment. The carriage of an EPIRB is not a mandatory/regulatory requirement for vessels such as the Kella-Lee. When activated, an EPIRB transmits a distress call which is picked up or relayed by satellites and transmitted via land earth stations to rescue services. The EPIRB was found strapped to the owner/operator's right leg. Its activating switch was in the off position. The due date for the replacement of the battery was December1994. It is not known if the EPIRB was functional. Steering Gear Malfunction The vessel had experienced problems with the steering system prior to this occurrence. The loss of hydraulic fluid from a leaking solenoid valve rendered power and hand stand-by hydraulic systems inoperative. The rudder could have been turned by means of a jury-rigged hand tiller from outside the lazarette, however this was not an option given the prevailing weather conditions. Generally, in small fishing vessels, the lazarette houses the rudder stock and hydraulic steering ram along with hydraulic lines and valves. Atmospheric conditions within the lazarette are conducive to condensation and moisture and consequent corrosion of valves and hydraulic lines. Life-saving Appliances The WCB regulations require that an immersion suit, meeting standards acceptable to the WCB, be carried for each crew member on board, however, no specific standards are formalised. During the course of random inspections of fishing vessels, WCB prevention officers occasionally insist on the crew donning immersion suits. All three immersion suits on board the Kella-Lee were extra large size and differed from the actual physical sizes of the crew on board. One of the survivors, who spent considerable time in the water, reported ingress of water through the suit collar because the suit was too large for him. Ship Safety Bulletin (SSB) No.03/2001, refers to the stowage requirements of liferafts and inflatable rescue platforms. It recommends that all vessels, irrespective of size, stow liferafts (other than davit launched rafts) and inflatable rescue platforms so that they float free in the event of the vessel sinking. This can be achieved in two ways, by stowing liferafts in deep chocks without lashing, or by securing the liferaft with a lashing fitted with a hydrostatic release unit. The stowage of the liferaft on the Kella-Lee did not meet either of these requirements. The liferaft on the Kella-Lee was placed on top of the wheelhouse because of space limitations and to avoid obstruction during fishing. However, fishing industry operators report that this location, when close to the paravane booms and rigging, may interfere with the safe deployment of the raft. In this occurrence, the painter became entangled with the boom and its rigging, and increased the risk of damage to the liferaft, injury to the crew and the danger of the liferaft and crew being dragged down with the vessel. Decision to Fish in Queen Charlotte Sound Although aware of the weather forecast predicting gales and storms, the owner/operator decided to fish at a location some 14hours from the nearest shelter, fished in adverse sea conditions and did not stop fishing in sufficient time to allow a safe passage to Port Hardy. General Requirements for Vessel Insurance During the process of vessel insurance, the insurance companies operate on the assumption that the owner will correct the deficiencies noted on the report and keep the vessel operationally safe. Surveys and consistency in follow-up to surveys by insurance companies would encourage owners to correct identified deficiencies and also help ensure safety-critical items are taken care of and would complement the inspection regime of TC and the WCB. This procedure would enhance safety within the fishing industry. Fish Hold Hatch Covers Although the main hatch to the fish hold of the Kella-Lee was properly secured, the two small flush-fitting access openings within the main hatch cover, though fitted with means of securement, were not. Section23 of the SFVIR states that, ...hatchways on a fishing vessel shall be provided with efficient means for battening them down and making them watertight. During TC inspections, these hatches are not tested for water-tightness but are subjected to a visual inspection to ensure adequate lashing arrangements are available. Generally hatch covers on vessels such as the Kella-Lee are not constructed to be watertight and can be, though only when covered and held down with tarpaulins and strongbacks. Most hatch covers sit atop and overlap raised deck coamings. Moreover, the small lift-out access hatches atop the main hatch cover are not normally lashed down. The general, though mistaken, assumption within the fishing fleet is that in inclement weather, the loss of these covers is unlikely. Due to its workload it is not possible for TC to inspect all small fishing vessels for this requirement. It is therefore very important that fishermen are aware of the importance of securing hatch covers. TC has issued numerous SSBs on maintaining the watertight integrity of fishing vessels,6 some as a result of TSB recommendations. The following TSB Recommendation (see TSB Reports M93M4004, M90L3034) was made in an effort to prevent accidents due to hatch openings: The Department of Transport develop and implement measures to ensure that owners, operators and masters of vessels under its jurisdiction have effective training and procedures for securing all exterior openings sufficient to preserve the watertight integrity of the hull for the environmental conditions being encountered. (M93-01) SSBs were issued to the industry, however, training for owners/operators was not addressed. Search and Rescue Operations One fixed wing Buffalo aircraft and a Labrador helicopter7 were tasked from CFB Comox. The Labrador helicopter is capable of taking off and landing in winds of up to 45knots and once airborne, is able to fly in winds greater than 45knots. However, high winds of 78-88knots together with low cloud ceilings, poor visibility and icing in cloud precluded the aircraft from responding. The helicopter could not respond until conditions improved. The fixed wing Buffalo aircraft, when tasked, normally carries one SKAD (Survival Kit Air Droppable) and one pump unless the occurrence warrants otherwise. Due to the severity of the prevailing weather and poor visibility on the scene, the crew of the Buffalo aircraft could not ascertain if the two lights sighted were those of the liferaft or of persons in the water, and anticipating the ineffective use of the only SKAD unit on board, it was not dropped. There was a period of approximately 2.4hours with no air coverage when the Buffalo aircraft, R452, had to return to Port Hardy to refuel. Before doing so, it dropped a datum marker buoy to mark the area for surface vessels proceeding to the scene. The second tasking was within the limits outlined in the National SAR Manual. It is not known if survivors would have been found earlier with constant air coverage. Shortly after arriving on the scene, the second tasked Buffalo aircraft, R465, dropped flares which allowed the CCGS JohnP.Tully to sight the liferaft, however, the visibility was so bad that sight of it was lost when the flares were spent. The belated departure from the fishing grounds some 16.7hours after receiving a storm warning and possible hurricane force winds in the area in which the Kella-Lee was fishing exposed the vessel to extreme sea and wind conditions. The malfunction of the steering gear and the sporadic partial loss of propulsion caused the loss of steerage way and directional control, leaving the vessel highly vulnerable to the full force of the high winds and heavy seas. The partial removal of permanent ballast from the engine-room, and the weight of additional fishing gear installed above the main deck, raised the centre of gravity of the vessel and reduced the original as-built (and approved) transverse stability characteristics. The weight and free-surface effects of the water shipped and retained on deck, together with the heeling effect of the riding sail and dynamic rolling effects of the high winds and heavy seas, combined to overcome the vessel's righting ability and caused the extreme angle of heel from which she was unable to recover. The open top half of the weather-tight door to the accommodation area, the unsecured flush-fitting access hatches to the engine-room, and the unsecured access panels in the main fish hold hatch cover compromised the watertight integrity of the vessel. The vessel down-flooded, lost all reserve buoyancy and sank.Findings as to Causes and Contributing Factors The belated departure from the fishing grounds some 16.7hours after receiving a storm warning and possible hurricane force winds in the area in which the Kella-Lee was fishing exposed the vessel to extreme sea and wind conditions. The malfunction of the steering gear and the sporadic partial loss of propulsion caused the loss of steerage way and directional control, leaving the vessel highly vulnerable to the full force of the high winds and heavy seas. The partial removal of permanent ballast from the engine-room, and the weight of additional fishing gear installed above the main deck, raised the centre of gravity of the vessel and reduced the original as-built (and approved) transverse stability characteristics. The weight and free-surface effects of the water shipped and retained on deck, together with the heeling effect of the riding sail and dynamic rolling effects of the high winds and heavy seas, combined to overcome the vessel's righting ability and caused the extreme angle of heel from which she was unable to recover. The open top half of the weather-tight door to the accommodation area, the unsecured flush-fitting access hatches to the engine-room, and the unsecured access panels in the main fish hold hatch cover compromised the watertight integrity of the vessel. The vessel down-flooded, lost all reserve buoyancy and sank. Current regulations only require initial and on-going stability data approval for small fishing vessels engaged in the herring or capelin fisheries. For other small fishing vessels, the onus for maintaining stability rests with vessel owners. The Kella-Lee's stability data was initially submitted by the owner and approved by the (then) CSI. After approval however, the removal of some of the permanent ballast was neither formally reported to TC nor brought to the attention of TC inspectors at several successive quadrennial inspections. A reassessment of the vessel's stability after the removal of ballast and the addition of fishing gear was not carried out by a competent person. Regulatory inspections by TC, and routine vessel operation by the owner, did not identify or ensure remedial action was taken with regard to safety-related factors, including: the absence of standard regulatory life-saving equipment (lifejackets lifebuoys); and the insufficient number and inappropriate sizes of immersion suits. The location of the inflatable liferaft stowage, abreast and inboard of the starboard side paravane boom and rigging, obstructed and prevented safe deployment of the liferaft. The inspection and battery replacement dates of the recovered EPIRB were March1993, and December1994, respectively, and in the event, no signal was received from it.Findings as to Risk Current regulations only require initial and on-going stability data approval for small fishing vessels engaged in the herring or capelin fisheries. For other small fishing vessels, the onus for maintaining stability rests with vessel owners. The Kella-Lee's stability data was initially submitted by the owner and approved by the (then) CSI. After approval however, the removal of some of the permanent ballast was neither formally reported to TC nor brought to the attention of TC inspectors at several successive quadrennial inspections. A reassessment of the vessel's stability after the removal of ballast and the addition of fishing gear was not carried out by a competent person. Regulatory inspections by TC, and routine vessel operation by the owner, did not identify or ensure remedial action was taken with regard to safety-related factors, including: the absence of standard regulatory life-saving equipment (lifejackets lifebuoys); and the insufficient number and inappropriate sizes of immersion suits. The location of the inflatable liferaft stowage, abreast and inboard of the starboard side paravane boom and rigging, obstructed and prevented safe deployment of the liferaft. The inspection and battery replacement dates of the recovered EPIRB were March1993, and December1994, respectively, and in the event, no signal was received from it. TC records show that SIC29s, signifying the successful completion of the regulatory ship safety inspection process, were not issued following hull and machinery inspections in1989,1993and1997, and at the time of the occurrence the vessel was operating without a completed SIC29. The routine quadrennial inspection, due in2001, had not been carried out at the time of the loss of the vessel. The on-scene arrival of the Labrador helicopter was delayed due to local wind speeds, low cloud ceiling, poor visibility and icing in cloud. Surveys and follow up by insurance companies would complement TC and WCB inspection requirements and foster safety. The atmospheric conditions within the lazarette may have fostered the deterioration of the valves and hydraulic lines of the steering system which likely caused the steering failure.Other Findings TC records show that SIC29s, signifying the successful completion of the regulatory ship safety inspection process, were not issued following hull and machinery inspections in1989,1993and1997, and at the time of the occurrence the vessel was operating without a completed SIC29. The routine quadrennial inspection, due in2001, had not been carried out at the time of the loss of the vessel. The on-scene arrival of the Labrador helicopter was delayed due to local wind speeds, low cloud ceiling, poor visibility and icing in cloud. Surveys and follow up by insurance companies would complement TC and WCB inspection requirements and foster safety. The atmospheric conditions within the lazarette may have fostered the deterioration of the valves and hydraulic lines of the steering system which likely caused the steering failure. Safety Action Action Taken The Board, concerned about the safety of small commercial fishing vessels has, over the years, initiated safety communications including recommendations. The following summarizes initiatives and progress made to date: Safety Awareness Promotion: During the period 01January2001 until the loss of the Kella-Lee on 26October2001, the TSB assessed a total of 24occurrences on the Pacific Coast, including that of the Kella-Lee; 21involved 26small fishing vessels, and the other 2involved small tugs. These occurrences included fires, capsizings, sinkings, floodings and groundings. As a result of these occurrences 9lives were lost and a number of seamen were seriously injured, 3vessels were declared constructive total losses, 8vessels sank and others sustained extensive damage. Most of these vessels were under 15gross tons and most of the re-occurring deficiencies found were common to all. In light of these happenings, and after the loss of the Kella-Lee, an Inter-Agency Marine Action Group (MAG) was created with the mandate to promote safety awareness, provide safety education and foster safe operating practices within the marine community. The group's objective is to reduce the high accident rate in the fishing/marine industry. These occurrences often result in death or injury to crews. At present these agencies include: Transport Canada (TC); the Transportation Safety Board of Canada (TSB); the Workers' Compensation Board of B.C. (WCB); the Department of Fisheries Oceans, Fisheries Management (DFO); the Canadian Coast Guard, which represents the Coast Guard Auxiliary (CGA), the Marine Communications and Traffic Services (MCTS) and the Office of Boating Safety (OBS); and the B.C. Seafood Alliance. TC has recently revised and reprinted the Small Fishing Vessel Safety Manual (TP10038). This manual addresses many of the factors which have contributed to small fishing vessel occurrences. The manual is especially useful in that it describes in very simple, easy to understand terms, complex factors that can have serious consequences to the safety of small fishing vessels, providing simple solutions to avoid such consequences. TC is presently in the process of distributing this manual to the general fishing community. Follow-up on Vessel Inspections: TC is now using a new Ship Information Reports system to keep track of vessel inspections. This system incorporates enhanced auditing functions that will ensure follow-up on vessel inspections. It will aid in ensuring that owners complete all the outstanding items resulting from quadrennial inspections and that TC subsequently issues a valid S.I.C.29. Modification to Vessels: The failure of the fishing vessel owners/operators to report these modifications to the nearest TC Marine Safety office, even though it is required by regulation, has been an ongoing problem. Realizing that a more effective method has to be found to address this problem TC, along with the Canadian Marine Advisory Council Standing Committee on Fishing Vessel Safety, is investigating the feasibility of enhanced enforcement methods regarding the reporting of modifications to fishing vessels. Stability Requirements: As part of the Canada Shipping Act 2001Regulatory Reform Fishing Vessel Safety Regulations Project, a sub-project has been initiated to evaluate and establish mandatory stability requirements that would be applicable to all fishing vessels less than 24metres in length overall, regardless of the type of fish they are engaged in catching. Coordination between TC and DFO: TC has acknowledged the need to have better coordination between the issuance of fishing licences and ship inspection certificates. Towards that end, TC has initiated discussions with the Department of Fisheries and Oceans to explore the feasibility and possible methods whereby such coordination could be achieved. These discussions are ongoing.